Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | RPT614 | ID |
N | 2251S0007X | Physical Therapist - Sports | RPT614 | ID |
N | 2251X0800X | Physical Therapist - Orthopedic | RPT614 | ID |
NPI | 1124110002 |
---|---|
Provider Name | John C Koth |
First Address | Ketchum, ID 83340-1510 |
Second Address | Ketchum, ID 83340-1510 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/09/2006 |
Last Update Date | 17/01/2014 |